Adult Attention Deficit Hyperactivity Disorder

Adult ADHD/ADD

Fareed A. Minhas

Professor of Psychiatry

Head, Institute of Psychiatry

Over-view

Wood et al j clin psychiatry 2002:63

Although first identified in children in the 19th century, adult ADHD was not described in literature till 1976.

Attention-deficit/hyperactivity disorder (ADHD) in adults is a common disorder associated with global and significant impairments in occupational, academic, neuropsychological, and social functioning.

However, because the disruptive outward manifestations of ADHD (e.g, hyperactivity) decrease with age, adult ADHD remains somewhat hidden and under diagnosed.

Faraone SV, Biederman J, Spencer T, et al. Attention-deficit/hyperactivity disorder in adults: an overview. Biol Psychiatry. 2000;48:9-20

In the past 15 years, there has been an increasing awareness of the syndromal persistence of attention-deficit/ hyperactivity disorder (ADHD) into adulthood.

Once considered only a childhood disorder, ADHD has become increasingly recognized as a valid psychiatric disorder in adults.

Comparisons with Pediatric ADHD and Prevalence

Simon Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis The British Journal of Psychiatry (2009)

In children, the prevalence of ADHD is typically cited as between 3% and 5% of the general population while in adults, studnies suggest that the prevalence is about 4%.

Longitudinal research indicates that the majority (50% to 70%) of children with ADHD continue to show impairing symptoms as they age.

Gershon J. A meta-analytic review of gender differences in ADHD. J Atten Disord 2002; 5: 143-54.

Compared with pediatrics and adolescent studies, adult ADHD studies have generally shown a more balanced distribution of prevalence in men and women.

This may be attributable to the fact that whereas childhood referrals are usually initiated by parents or teachers, in adulthood self-referrals are common.

Co-morbidity

Biederman J, Newcorn J, Sprich S. Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other

disorders. Am J Psychiatry. 1991;148:564-577

Adult ADHD is associated with co morbid mood, anxiety, anti social personality and substance use disorder diagnoses.

However, and some data suggest that uncomplicated ADHD exists in about 20% to 25% of adults with ADHD

Genetics and Heritability Index in Adult ADHD

Biederman J, Newcorn J, Sprich S. Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other

disorders. Am J Psychiatry. 1991;148:564-577

ADHD is a highly heritable condition

When ADHD persists into adulthood, it is decidedly familial.

Biederman and colleagues found a 57% prevalence of ADHD in children of adults with the disorder, which is much higher than the 15% prevalence of ADHD among siblings of children with ADHD.

A prospective ADHD study with a 4-year follow-up examined 140 boys with ADHD and 120 boys without ADHD at baseline.

Parents of persistent ADHD probands were 20 times more likely to have ADHD than parents of controls.

Parents of non persistent ADHD probands showed only a 5- fold increased risk.

Siblings of persistent ADHD probands were 17 times more likely to have ADHD than siblings of controls, while siblings of nonpersistent ADHD probands showed only a 4-fold increased risk

Brain Imaging Data of adult ADHD

Most work has considered the impairment of executive functions (motor execution, inhibition, working memory), and as such a number of attention networks and their anatomical correlates (e.g. the cerebello-(Thalamo-)-Striato-cortical network seems to play a pivotal role in ADHD pathology from childhood to adulthood)

Early studies suggested that individuals with ADHD had smaller total cerebral volume and showed loss of the normal asymmetry in the size of the caudate nucleus (Castellanos et al., 1996).

Newer Neuroimaging assays have most consistently implicated abnormalities of the dorsal prefrontal cortex and basal ganglia in the pathophysiology of ADHD.

Reduced metabolic rates have been reported in the left and in the premotor and superior prefrontal cortices of adults with ADHD

Two ligand-based SPECT studies of adults diagnosed with ADHD reported marked elevations of dopamine transporter levels in the basal ganglia (Dougherty et al., 1999; Krause et al., 2000

After four weeks of 5 mg methylphenidate treatment three times daily, decreased to control levels

Functional Impairments

Recently published longitudinal research findings indicate that ADHD in adults is a far more impairing disorder than many other disorders (eg, anxiety and mood disorders) across multiple domains of major life activities, especially

educational occupational functioning money management more accidents and near-accidents marital and interpersonal relations problems & management of daily responsibilities

Wilens TE, Dodson W. A clinical perspective of attention-deficit/hyperactivity disorder into adulthood. J Clin Psychiatry. 2004;65:1301-1313

Schubiner H, Tzelepis A, Milberger S, et al. Prevalence of attention-deficit/hyperactivity disorder and conduct disorder among

substance abusers. J Clin Psychiatry. 2000

Elevated prevalence of substance abuse/dependence has consistently been reported in adults with ADHD

An estimated 17% to 45% of adults with ADHD have histories of abuse or dependence and 9% to 30% have histories of drug abuse or dependence.

Studies have shown that compared with adults who do not have ADHD, adults with co morbid ADHD and substance abuse/dependence have an earlier onset and a greater severity of substance abuse

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Steps in the diagnosis of attention-deficit hyperactivity disorder (ADHD) in adults

1. Assess current ADHD symptoms (within the last 6 months) using rating scales with adult norms.

2. Establish a childhood history of ADHD.

3. Assess functional impairment at home, work and school and in relationships.

4. Obtain developmental history, including during prenatal, childhood and school years

5. Obtain psychiatric history: rule out other psychiatric disorders or establish comorbid diagnoses (e.g., learning disabilities, mood and anxiety disorders, personality disorders and substance abuse, especially marijuana abuse

6.Obtain family psychiatric history, especially concerning learning problems, attention and behaviour problems, ADHD and tics. Enquire about all first-degree relatives (parents, siblings and offspring).

Diagnosis

Criteria for ADHD are specified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV)

DSM-IV describes 3 subtypes of ADHD Predominately hyperactive Predominately inattentive Mixed type with symptoms of other 2 categories

Criticisms of DSM-IV

Never been validated in adults Doesn’t include developmentally appropriate

symptoms for adults Fails to identify some significantly impaired

adults who would benefit from treatment The subtlety and subjectivity of ADHD

symptoms in adults and the absence of a single gold standard for confirming diagnoses makes assessment challenging

Wender UTAH criteria

Ward MF, Wender PH, Reimherr FW: The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J

Psychiatry  1993; 150:885–890; correction, 150:1280

The Utah criteria proposed by Wender for use in diagnosis of adult ADHD require a retrospective childhood diagnosis, ongoing difficulties with inattentiveness and hyperactivity, and at least two of the remaining five symptoms.

Seven symptom clusters were proposed to characterize the phenomenology of adult ADHD, namely

1) inattentiveness 2) hyperactivity 3) mood lability 4) irritability and hot temper 5) impaired stress tolerance 6) disorganization, and 7) impulsivity

Clinical presentation Adult ADHD patients complain of: Difficulty with concentration, attention, and short-

term memory. The most common psychiatric conditions that may

have overlapping symptoms with adult ADHD include Mood disorders Anxiety disorders Substance use disorders Antisocial personality disorder and borderline

personality disorder Developmental disabilities or mental retardation Medical conditions

Performance Testing and Psychological Testing

Ward MF, Wender PH, Reimbers FW. The Wender Utah rating scale: An aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry. 1993;150:885–90. Erratum in: Am J

Psychiatry 1993

Copeland Symptom Checklist for Adult ADHD, a three-point severity rating scale for a broad range of cognitive, emotional, and social symptoms filled out by the patient

The Wender Utah Rating Scale, a retrospective five-point severity rating scale of childhood ADHD symptoms filled out by the patient

The Brown Adult ADHD Scale, a four-point frequency rating scale for cognitive symptoms associated with difficulty initiating and maintaining optimal arousal level completed by the patient

The Pilot Adult ADHD Self-Report Scale (ASRS), which is a frequency-based scale that matches the 18 items in theDSM

Management

Treatment consists of 3 parts: providing education about ADHD psychological support to the patient and

family medication treatment follow-up and continued support.

Psychological treatment

Education about the disorder Patients should be told that ADHD is a

neurobiological developmental disorder, with further explanation of the relation between symptoms and maladaptive behaviours.

Coping strategies and skills training How to use a day planner, developing

routines for meal time, delegating challenging tasks

Bemporad JR. Aspects of psychotherapy with adults with attention deficit disorder. Ann N Y Acad Sci 2001;931:302-9.

Cognitive behavior therapy training of parenting skills for adult parents

with ADHD vocational counseling educational remediation

Pharmacological treatment Medication has been the first line of treatment

of ADHD and has been shown to be effective and safe in adults and in children.

A trial of stimulant medication requires titrating doses while monitoring ADHD symptoms (by means of serial administration of a rating scale) and side effects (e.g., hypertension, insomnia, headaches, weight loss).

Wilens TE, Spencer TJ, Biederman J. A review of the pharmacotherapy of adults with attention-deficit/hyperactivity disorder. J Atten Disord

2002;5(4): 189-202.

A meta-analysis of the findings from these studies showed a weighted mean response rate of 57% to methylphenidate, 58% to dextroamphetamine and 10% to placebo.

Studies have suggested that symptom reduction is dose dependent, with higher response rates accompanying higher doses

Monitoring requires that the patient take the medication every day for 1 week.

The optimal dose is achieved when no further reduction in ADHD symptoms occurs and side effects are still judged to be manageable.

Wilens TE, Biederman J, Prince J, Spencer TJ, Faraone SV, Warburton R, et al. Six-week, double-blind, placebo-controlled study of desipramine for adult attention deficit hyperactivity disorder.

Am J Psychiatry 1996;153(9):1147-53

If the patient does not respond to or tolerate stimulant medication, treatment with an antidepressant may be considered.

Double-blind, placebo-controlled studies of the efficacy of buproprion, desipramine are useful in the management of ADHD in adults

Antidepressants in adults with ADHD is similar to the response in children, with 50%–66% of patients showing a clinically significant response.

Atomoxetine

Atomoxetine was approved by the FDA November 2002.

Classified as a norepinephrine (noradrenaline) reuptake inhibitor atomoxetine is approved for use in children, adolescents, and adults.

Atomoxetine may be preferred over amphetamine-based stimulants in patients with psychiatric disorders, those who cannot tolerate stimulants, and those with a substance misuse recurring history

Once- or twice-daily atomoxetine is effective in the short-term treatment of ADHD in adults, as observed in several placebo-controlled trials.

A single morning dose was shown to be effective into the evening, and discontinuation of atomoxetine was not associated with symptom rebound.Prasad S, Steer C (2008). "Switching from neurostimulant therapy to

atomoxetine in children and adolescents with attention-deficit hyperactivity disorder

ADHD Screening and diagnostic scales

Diagnosis of ADHD in Adults is a tricky one, due to the following:

  It being a spectrum disorder, it may present with

different symptoms or intensity of symptoms across the life span.

A high quality developmental history is required to confirm the diagnosis, which sometimes is not available

There is an overlap of symptoms with other mental disorders like Autism Spectrum Disorders, Personality Disorders, and many other conditions.

“ADHD like traits” can be present in normal people, which cumulatively don’t qualify the diagnosis.

Secondary conditions and comorbidities sometimes make accurate diagnosis more confusing.

Rating Scales Wender Utah Scale is a self rated/ observer

rated scale Adult ADHD Self-report Scale Conner’s Adult ADHD Rating Scale Brown Attention Deficit Disorders Scales

Wender Uttah ADHD rating scale Aids in screening and diagnosis Self rating scale 61 item scale Cut off point – 46 Maximum score 100

Adult ADHD self report scale 18-Item scale Self screening tool 9 items for inattention 9 items for hyperactivity Takes approximately 5 mins It can assess the likelihood of a diagnosis and

is useful as a diagnostic aid after an initial screening

Conner’s adult ADHD rating scale (CAARS)

Both clinician administered and self rated versions

Measure frequency and severity of symptoms “ loses things necessary for tasks and

activities” “appears restless inside even when sitting still

30- item frequency scale

Brown attention deficit disorders scale

40-Item frequency scale Clinician rated and self report forms Explores the executive functioning aspects of

cognition associated with ADHD “is excessively forgetful about what has been

done, said or heard in the past 24 hours” “Is easily frustrated and excessively

impatient”

Once the patient has been screened positive

Wender-Reimherr Adult Attention Deficit Disorder Scale gives the severity of seven target symptoms

Structured Clinical Interviews include:

Wender-Reimher Interview, Conner’s Adult ADHD Interview

Structured Clinical Interview for DSM-IV (SCID)

Schedules for Clinical Assessment in Neuropsychiatry (SCAN)

Mini International Neuropsychiatric Interview (MINI)

Composite International Diagnostic Interview (CIDI).

A thorough Neuropsychological Assessment of Executive Functions may give clues to the diagnosis.

Simple things like Stroop Test highlights issues with executive function like set shifting.

 

Robust diagnosis of ADHD is based upon:1.     Family History as ADHD is highly inheritable.2.     Development History, symptoms presenting at a young age.3.     Present symptoms.4.     Separating co-morbidity or secondary psychopathology from the primary one.

At the end of day treatment outcome is the best indicator of the presence of disorder in the adulthood.

THANK YOU Email: minhas.fa@gmail.com